{
  "abstract": "Objective: Choosing between noninvasive respiratory support (NIRS) and invasive mechanical ventilation (IMV) for acute respiratory failure is a time-sensitive decision. Although guidelines provide population-level guidance, it remains unclear who benefits more from NIRS than IMV. The standard outcome, ventilator-free days at 28 days (VFD-28), scores death and prolonged ventilation equally, and current estimators do not distinguish between them. We developed and validated a censoring-aware Digital Twin framework for Individualized Treatment Effects of Non-Invasive Respiratory Support (DINIRS) to estimate individualized treatment effects (ITEs) that capture both mortality and ventilation duration. Materials and Methods: We emulated a target trial in 5,336 MIMIC-IV patients and trained DINIRS on 23 baseline clinical variables measured during the first 24 ICU hours. A transformer encoder with a survival attention gate decomposed VFD-28 into survival probability and conditional ventilation duration. A cross-fitted, doubly robust learner estimated ITEs. We externally validated DINIRS in 2,540 patients from the multi-site eICU-CRD dataset without retraining. Results: The DINIRS policy achieved a mean benefit of 2.07 ventilator-free days per patient (207 per 100 patients) compared with observed practice. Predicted NIRS benefit was higher among patients with less organ dysfunction (88.4% versus 49.0%) and persisted across hypoxemia severity. External validation reproduced this pattern. Discussion: The NIRS benefit stemmed from shorter ventilation among survivors rather than from reduced mortality, indicating that avoiding intubation-associated complications was the primary mechanism. Conclusion: Prospective validation is needed before these estimates inform treatment decisions. The decomposition framework can be extended beyond respiratory support to any zero-inflated composite outcome.",
  "abstract_shown": true,
  "affiliations": [],
  "article_type": null,
  "arxiv": "2608.26915",
  "author_total": 3,
  "authors": [
    {
      "name": "Md Fantacher Islam"
    },
    {
      "name": "Jarrod Mosier"
    },
    {
      "name": "Vignesh Subbian"
    }
  ],
  "bibtex": "https://research.draconitic.com/paper/7kv0097mawwsw.bib",
  "cited_by": 0,
  "doi": "10.48550/arxiv.2608.26915",
  "fulltext_url": null,
  "id": "7kv0097mawwsw",
  "issns": [],
  "landing_url": "https://arxiv.org/abs/2608.26915",
  "language": null,
  "licence": "CC-BY-NC-SA-4.0",
  "licence_label": "CC BY-NC-SA 4.0",
  "licence_source": "article",
  "licence_url": "http://creativecommons.org/licenses/by-nc-sa/4.0/",
  "metadata_licence": "CC0-1.0",
  "native_subjects": [
    [
      "arxiv",
      "q-bio.QM"
    ],
    [
      "openalex",
      "2740|Respiratory Support and Mechanisms"
    ]
  ],
  "openalex": "W7204544434",
  "pdf_url": "https://arxiv.org/pdf/2608.26915",
  "pmcid": null,
  "pmid": null,
  "published": "2026-09-19",
  "publisher": null,
  "ris": "https://research.draconitic.com/paper/7kv0097mawwsw.ris",
  "sources": [
    {
      "first_seen": "2026-10-30T12:23:28Z",
      "native_id": "2608.26915",
      "source": "arxiv",
      "url": "https://arxiv.org/abs/2608.26915"
    }
  ],
  "subjects": [
    {
      "field": "biology",
      "origin": "arxiv:q-bio.QM",
      "subfield": "bioinformatics"
    }
  ],
  "title": "A Digital Twin for Individualized Treatment Effects of Non-Invasive Respiratory Support Strategies (DINIRS)",
  "title_text": "A Digital Twin for Individualized Treatment Effects of Non-Invasive Respiratory Support Strategies (DINIRS)",
  "type": "preprint",
  "updated_at": "2026-10-30T12:23:28Z",
  "url": "https://research.draconitic.com/paper/7kv0097mawwsw",
  "venue": "arXiv",
  "versions": []
}